Citation Nr: 1758052 Decision Date: 12/14/17 Archive Date: 12/28/17 DOCKET NO. 12-00 199A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD N. Miller, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1969 to July 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In May 2013, the Veteran testified at a hearing before the undersigned Veterans Law Judge via videoconferencing regarding his service connection claim for hypertension. A transcript of the hearing has been associated with the claims file. In December 2015, the Board remanded the appeal for further development. There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). FINDINGS OF FACT 1. The Veteran's hypertension did not originate during service, did not manifest to a compensable degree within one year of service separation, and was not caused or aggravated by his active service. 2. The Veteran's hypertension was not caused or aggravated by his service connected PTSD. CONCLUSION OF LAW The criteria to establish service connection for hypertension, to include as secondary to PTSD, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA has satisfied its duties under the Veteran's Claims Assistance Act of 2000 to notify and assist. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. § 3.102, 3.159, 3.326(a). VA's duty to notify was satisfied by a May 2009 letter informing the Veteran of the evidence generally needed to support his claim. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes helping claimants to obtain service treatment records and other pertinent records. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment and personnel records, along with VA medical records. The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159(c). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion necessary to make a decision on the claim. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326; see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The examinations and/or opinions must be adequate to decide the claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was afforded an in-person VA examination in January 2015. In accordance with prior remand directives, the VA examiner reviewed the claims file and provided addendum opinions with clear explanations in support of the opinions and findings. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion"). The VA examination and opinions are adequate to decide the Veteran's claim. Service Connection for Hypertension Service connection may be granted for a disability resulting from a disease or injury incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires (1) evidence of a current disability; (2) medical, or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Hypertension is a "chronic disease" listed under 38 C.F.R. § 3.309(a). Therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303 (b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time is required. If a disease is shown to be chronic during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected unless they are clearly attributable to intercurrent causes. Generally, if a condition noted during active service is not shown to be chronic, then, a "continuity of symptoms" after service is required to establish service connection. 38 C.F.R. § 3.303(b). Additionally, as a chronic disease, hypertension will be considered to have been incurred in or aggravated by service if the disease becomes manifest to a compensable degree within one year from the date of service separation. 38 C.F.R. § 3.307(a)(3). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id.; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In deciding an appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabriel v. Brown, 7 Vet. App. 36, 39 - 40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Further, competency of evidence differs from the weight and credibility of evidence. Competency is a legal concept that determines whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination regarding the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). In regards to the competency of lay evidence, the Board must determine, on a case-by-case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms, as symptoms require only personal knowledge of what is observed through the use of his senses, not medical expertise. See Layno, 6 Vet. App. At 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. See Barr, 21 Vet. App. at 307 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. See Jandreau, 492 F.3d at 1377. VA is responsible for determining whether the evidence supports the claim, with the veteran prevailing, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The Veteran's service treatment records are silent as to any treatment for hypertension. On his physical examination reports for service entry and separation, no indication of hypertension was noted. At the hearing, the Veteran testified he was diagnosed with hypertension in 2002. VA medical records beginning in 2004 show the Veteran had several blood pressure readings and he was placed on medication to help control his blood pressure. In October 2004, the Veteran's physician noted he had hypertension of moderate degree, and by January 2007 it was considered to be under control. Further, in August 2009, August 2010, and August 2013 the Veteran's hypertension was classified as benign. In March 2015, the Veteran's blood pressure was borderline, with reported highs in the 160s systolic. However, it was determined this was linked to the Veteran only taking his medications when his blood pressure was elevated. The Veteran was encouraged to comply with the prescribed medication regimen. In January 2015, the Veteran had an in-person VA Examination, and the examiner provided addendum opinions in June 2015 and March 2016. At the in-person examination, the Veteran reported taking his medication about every other day. The examiner opined the Veteran's current hypertension was less likely than not caused or aggravated (i.e. permanently worsened) by his active service. The examiner explained that the Veteran was not found to have hypertension until 2003, several years after he left service. The examiner stated she was unable to find a documented connection of hypertension from the Veteran's time in service to the present hypertension condition, as his service treatment records do not show he was evaluated or treated for hypertension, nor was he diagnosed within one year of separation from service. The examiner also opined that it is less likely than not that the Veteran's current hypertension was caused or aggravated by his service connected PTSD. The examiner noted that a review of the Veteran's blood pressure readings since 2003 do not show excessively high blood pressure reports. The examiner stated that she consulted with VA mental health and cardiology specialists, and the consensus was that periods of increased stress can predispose to elevations of blood pressure. However, the examiner found that after consulting with the specialists and reviewing the medical literature, no new research has been found to identify PTSD as a "direct cause" of hypertension. In regards to whether the Veteran's service connected PTSD permanently aggravated his hypertension beyond its normal progression, the examiner stated she was unable to identify permanent aggravation at this time. In support of her finding, the examiner stated the Veteran is currently on hypertension medication, and the majority of his blood pressure readings since 2003 were at goal or in the Stage 1 hypertension range (systolic 140 - 159 mmHg. or diastolic 90 - 99 mmHg.) A preponderance of the evidence is against a finding that the Veteran's hypertension originated during service, was manifest to a compensable degree within one year of service separation, or was caused or aggravated by his service-connected PTSD. The earliest report of being diagnosed with hypertension occurred in 2002, more than 30 years after separation from service. No competent medical provider has opined that the Veteran's hypertension was caused or aggravated by his PTSD. At the hearing, the Veteran testified that one of his physicians has verbally relayed that his hypertension worsens when he experiences PTSD symptoms, but that the physician has not provided this assessment in writing to be included in the record. In support of the contention that his hypertension is secondary to his service connected PTSD, the Veteran provided abstracts from medical literature published in 2009 and 2011 discussing research that linked hypertension to PTSD in Vietnam veterans from Australia. Though the abstracts indicate there may be a correlation between PTSD and hypertension in other individuals, they are not sufficient to serve as the required medical nexus evidence to establish a connection between the Veteran's hypertension and service connected PTSD. The probative value of the abstracts do not outweigh the medical opinion of the VA examiner who not only examined the Veteran in-person, but also consulted with specialists, reviewed the claims file, and reviewed medical literature to formulate an opinion regarding the Veteran's hypertension. Accordingly, service connection for hypertension is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 53-56. ORDER Service connection for hypertension is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs